=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588384986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON SIMONIDES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 CHASE PKWY
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-755-6677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 FIELD ST
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-899-7897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 031862
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------